Table of Contents (TOC)

Heroin Overdose Deaths --- Multnomah County, Oregon, 1993--1999

In the United States, heroin use is increasing and was
implicated in 3805 deaths in 1993.1 Multnomah
County is Oregon’s most populous county (1998 estimated
population: 641,900); three fourths of county residents
live in Portland. In 1999, in response to community concerns,
the Multnomah County Health Department analyzed medical
examiner (ME) data for 1993--1999 and interviewed heroin
users to characterize heroin overdose deaths (HODDs) in
the county. This report summarizes the findings of these
studies, which indicate that HODDs in the county more than
doubled from 1993 to 1999 (from 46 to 111), and that interviews
with users helped identify possible public health interventions.

For 1993--1999, ME-diagnosed HODDs were identified using
the ME annual summary of drug-related deaths. For 1996--1999,
the Multnomah County Health Department conducted a detailed
review of ME records of drug-related deaths, which included
those resulting from overdose and other drug-related causes
(e.g., injury and disease deaths in which drugs played a
role). ME-diagnosed HODDs for 1996--1999 were within 6.5%
of those identified in the detailed case review.

During 1993--1999, 573 ME-diagnosed HODDs were identified.
During 1996--1999, 517 drug-related deaths occurred in Multnomah
County; 85 attributed to causes other than unintentional
overdose (e.g., homicide and suicide) were excluded. Of
the remaining 432 deaths, 389 (90.0%) were classified as
unintentional HODDs based on laboratory evidence of opiates
in blood or other specimens and absence of historic, scene,
or toxicologic evidence of poisoning with other drugs, including
other opiates. Of the 389 HODDs, 337 (86.6%) were in Multnomah
County residents. HODDs more than doubled from 1993 (n=46)
to 1999 (n=111) (Figure 1). In 1999, the cause-specific death rate from HODDs
among all county residents was 15.1 per 100,000 population.

Of the 389 HODDs, 333 (85.6%) were in males. Almost half
(46.8%) were in persons aged 45--54 years; 23.1%, aged 35--44
years; 22.9%, aged 25--34 years; and 4.9%, aged <25 years.
The median ages for males (40.0 years) and females (37.5
years) were similar. The race/ethnicity of persons who died
of heroin overdose reflected the county population.

Approximately half (47.6%) of HODDs occurred in users’
homes, 13.4% occurred in friends’ homes, and 13.4% in hotels/motels.
Only 18.8% of the HODDs occurred in public settings where
a passerby might have found the person who had overdosed.

Toxicology results were analyzed for 115 consecutive HODDs
during October 1998--December 1999; for 58.3% of these HODDs,
alcohol and/or drugs in addition to heroin were detected.
The substances most commonly identified along with heroin
were cocaine (26.1%), benzodiazepines (15.7%), and alcohol
(10.4%).

To gather data on circumstances of overdose and identify
intervention opportunities, investigators interviewed heroin
users with a history of overdose. Ten current users were
recruited through posters in hotels and referrals from needle-exchange
programs. Eight former users early in recovery (i.e., abstinent
from heroin for <14 weeks) were recruited through a drug-free
housing program. Respondents were asked about 1) drug availability,
sources, cost, and potency; 2) drug use patterns; 3) personal
experience with heroin overdose; and 4) response to companion’s
overdose.

Respondents reported that "black tar" heroin from Mexico
or South America was the primary type used in the community
and that heroin and other drugs are readily available and
inexpensive. Users reported great variability in the potency
of heroin sold in Multnomah County. Users also reported
that injection was the primary route of administration.

Regular heroin users develop tolerance to higher doses.
When heroin use is interrupted, heroin doses that were previously
well-tolerated can cause overdose. Heroin users described
several situations in which heroin use was interrupted:
involuntarily, when incarcerated or lacking money to purchase
heroin, and voluntarily, during attempts to stop using heroin.
Regardless of the reason for the interruption, users reported
they tended to resume injecting heroin at their usual dose
and sometimes overdosed. Users believed that risk for overdose
was greater when they used alcohol and other drugs with
heroin, injected heroin without companions, and had another
person inject drugs for them.

Heroin users’ responses to a companion’s overdose reflected
a strong desire to avoid contact with law enforcement and
medical systems. Three fourths of respondents reported that
they hesitated to call for emergency assistance for fear
of being arrested. Many attempted to resuscitate overdosed
companions on their own. Users also described leaving overdose
victims in public places, hoping that they would be discovered
and helped by others.

Editorial Note

The findings in this report indicate that HODDs are a major and increasing
public health problem in Multnomah County. In 1999, it was a leading
cause of death among men aged 25--54 years, with a cause-specific death
rate of 47.8 per 100,000 population.

The ethnographic interviews provide some data about the circumstances
and risk factors for heroin overdose in Multnomah County. Variations
in heroin potency,2, 3 intermittent and interrupted heroin
use,4 use of other drugs and alcohol,5 and variable
heroin tolerance6 can increase the risk for overdose and death.
Failure to use emergency medical services has been associated with fatal
heroin overdose.7

The findings in this report are subject to at least four limitations.
First, surveillance for HODD is difficult because ME classification
of overdose deaths is inconsistent.8 Second, this study probably
underestimated the impact of heroin overdose on the county. Thirty-two
HODDs were excluded from the analysis because they were not clearly
unintentional overdoses, and 52 were excluded from death rate calculations
because they did not occur in county residents. Third, the difficulty
in reconstructing the social and behavioral context of overdose deaths
complicates both surveillance of HODDs and identification of prevention
opportunities. Finally, ethnographic data may not be representative
of injecting-drug users in Multnomah County because those interviewed
were from a convenience sample.

Several approaches may help to prevent HODDs. Improved public health
surveillance should enable identification of risks and protective factors
and help monitor the impact of interventions. Heroin use can be reduced
by primary prevention of the initiation of drug use and substance abuse
treatment (particularly methadone maintenance) for active users.

Other steps can be considered to reduce HODDs among users who cannot
or will not stop injecting. Improving use and quality of emergency medical
response and treatment can improve outcomes. Working with police to
establish policies that persons reporting or suffering drug overdose
are not subject to arrest could increase users’ willingness to seek
emergency assistance.9 Users can be counseled about the risks
for heroin overdose and how to avoid them.1, 9, 10 Some programs
train injecting-drug users and their partners in the use of naloxone,
an opiate antagonist highly effective in reversing the effects of opiate
overdose but that can induce withdrawal and requires medical supervision.1, 9

Implementing interventions to decrease heroin and other fatal drug
overdoses will require partnerships among a range of groups and programs,
including public health, substance abuse treatment, syringe exchange/community
outreach programs, emergency medical services, and police and criminal
justice departments. Planning and implementation should involve heroin
users because their knowledge, skills, and social networks can help
identify interventions and achieve acceptance of interventions among
the drug users at risk for drug overdose.